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HomeMy WebLinkAboutTR-10846A • Town Hall Annex P �v�Z� sot�T 54375 Route 25 Glenn Goldsmith. resident � p.p. Box 1179 A Nicholas Krupski, Vice President Southold, New York 11971 Eric Sepenoski Telephone (631) 765.1892: Liz Gillooly �® Fax (631) 765-6641 Elizabeth Peeples UNTI,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD SOUTHOLD TOWN BOARD OF TRUSTEES YOU ARE REQUI RED TO CONTACT THE OFFICE OF THE BOARD OF TRUST OFFEES 72 HOURS PRIOR TO COMMENCEMENT OF THE ACTIVITIE BE` INSPECTION SCHEDULE Pre-construction, hay bale line/silt boom/silt curtain 15� day of construction '/2 constructed When project complete, call for compliance inspection, J i Glenn Goldsmith,President ®f S®(/,� Town Hall Annex ��� ®�® 54375 Route 25 A. Nicholas Krupski,Vice President P.O. Box 1179 Eric Sepenoski l Southold, New York 11971 Liz Gillooly Q Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 COUNTI,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD Permit No.: 10846A Date of Receipt of Application: August 12, 2025 Applicant: Madeline C. Droege Family Revocable Trust, Dated-May 29, 2013 SCTM#: 1000-14-2-24 Project Location: 885 Pettys Drive, Orient Date of Resolution/Issuance: September 17, 2025 Date of Expiration: September 17, 2028 Reviewed by: Board of Trustees Project Description: The as-built removal of existing wood decking and installation of 1,305 sq.ft. composite decking. Findings: The project meets all the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code. The issuance of an Administrative Permit allows for the operations as indicated on the site plan prepared by,High House Woods Inc, received on June 13, 2025, and stamped approved.on September 17, 2025. Special Conditions: Establish and perpetually maintain a 10' non-turf buffer along top of bluff. Inspections: Final Inspection. If the proposed activities do not meet the requirements for issuance of an Administrative Permit set forth in Chapter 275 of the Southold Town Code, a Wetland Permit will be required. This is not a determination from any other agency. Glenn Goldsmith, President Board of Trustees CERTIFIED TO:MADI DROEGE JOB NO. 2015-280 MAP NO. 5859 APPROVED BY f FILED:JANUARY 26,1973 REVISIONS: BOARD OF 'i RUSTEES UPDATE SURVEY 11812021 REV. PROP. PARKING 21212021 of NEWy ADD DIMESNIONS TO TOWN OF SOUTHOLD ��Q' E� O,Q EXISTING DECK ADD SQ.FT. TO ALL c DATE O(J 0"n e r 3/ )-0)5 IMPERVIOUS ITEMS 7123125 ADD TRUSTEES 10'WIDE NON TURF BUFFER 9124125 �o47 _ cavo / 0 JEFFREY W. HADERER L.S. I NYS LIC. NO..050538 TWIN FOR LAND SURVEYING s S(7CfLSSOR719 HANLK'ON.SURVZ kING.MAR77ND.HAND LS. ' 1�� �0, 188 W.MONTAUK HIGHWAY,UNIT E3 EA �O. C�C'S'/ O� HAWTONYS,NEW YORK 11946 �y °� 9� (V)631-369- (E)691-369-8313 A email.•twinforkslankslandsurvey@yahoo.com �9�iQA_ COPIES OF THIS SURVEY MAP,EITHER PAPER OR ELECTRONIC,NOT BEARING Gyxiy� L? 9 O THE LAND SURVEYORS INKED SEAL OR EMBOSSED SEAL SHALL NOT BE `"q 1S CONSIDERED TO BE A VALID COPY AND SHALL NOT BE USED FOR ANY PURPOSE. LOT AREA:44,214 SQ.FT = 1.015 ACRES M LOT COVERAGE:6,170 SQ.FT = 14.0% (DOES NOT INCLUDE OVERLAPS) co nI� DWELLING:2,932 SQ.FT. \ FRONT PORCH.50 SQ.FT. STAKEFOUND \ NO TgCK DRONT STEPS: 18 SQ.FT \ FRONT WALKWAY. 160 SQ.FT. W \ FRONT OVER HANGS:94 SQ.FT. _ GREEN HOUSE SHED: 107 SQ.FT �o� WOOD RAMP&PLAT:26 SQ.FT o `5f, WOOD DECK: 1,305 SQ.FT C.E&STEPS:28 SQ.FT &36 SQ.FT WEST STEPS TO POOL PATIO. 13 SQ.FT W \ am NORTH STEPS:56 SQ.FT. STAKE Q FOUND \F r' 2nd FLOOR DECK OVER 1st FLOOR DECK:347 SQ.FT CONC. SLAB:49 SQ.FT o C\s�91� 'e°p� \ N PROPOSED STAIRCASE: 100 SQ.FT (38 SQ.FT. OVER CONC. SLAB) o \°soy y \ POOL.510 SQ.FT. COPING: 73 SQ.FT. PATIO. 621 SQ.FT. STNAKEFO OTACK D ems° Q 9•$s' `L a \ O SAUNA:30 SQ.FT. 70.3'x f0.4'-f07 SF FRAME 2 GRfEN7l0USE ' 7NC,SQFT • 5 J 1.TE �}7pA'O \ �QJ� W J AND P(q T26 c 2.6'W \ �W PNRDER GROUND 9 lam. 776. a SpJJ O m DPANETg7N IY 6g \ FRAME 1 1.2'W W V �OFC .� SAUNA Q STAKEFOUND __ h"- \ 30 SF NO TACK 14 14.8'-_ ?N�Fl�5S0 CON ON. pN O.TE O ry '� 36I o�sOF7k \ 0o ED �W 9 3 3• I"'� ?STjO4 O ' Z HEDGE O 2c w 19.0' 700�N F D p S C GFNFR° q 31.0' �1� GFNFF{I. U�T�,3A` 7p7 3ZSQFT I aC'(.PTOR o qNA' !� ti O 04,�q.0 • LFC7RiC 'V 7 G\ Lu 2 a�O STF M�FR �� 3e 4`vD� Nn��cR I O pUr x6STFP ; � R! 765E � iI� (n O � GA gCONC MON. FOUND )/ 06'E 06N A� - SURVEY OF LOT 6 OCT ?��� MAP OF PETTY'S BIGHT --- SITUA TE A T EASEMENTANCO YEVIXWAE STRUCTURES REGORGED OR UNRECORDED ARE RECORDED UNlE55 PHYSICALLY EV/QENi Ai TIE nW OF SURVEY THE ORIENT HEREON FRW (ORdMENLAOn S TO HER OFFSET MTNMAEAWTURES TO THE PROPERTY LINES ARE FOR ASRECIFIC TOWN OF SOUTHOLD PURPOS INTENO DTOGWEREFORE ARENOiI OFFENCES REIN THE ,V E s FNO's.1 S,RETNNING WALLS.POOlS,PATIO$.PLM'nNG SUFFOLK COUNTY, NEW YORK AREAS ADdTIONS 70 s.I NGS AND MY OTHER CONSTRUCnON. S.C.T M. 1000 SEC. 14 BLK. 02 LOT 24 UNAUTHMao LLTERAT,OV q ADdnON TO THIS 6URVEYAA V/OLAnON OF SECnON 7Mi OF THE NEW YORR STATE EDUCARONUW 20 10 0 20 40 60 80 100 120 140 160 180 COPIESOFTHISSURVEV MAPNOTBEAR/NG THE LAND SURVEYORS MEO SEAL OR SCALE: 1"=40' DATE.-OCTOBER 9, 2015 SEA TOEOSEA SHALLNOTBE CON90ERED To eE a vAllD nnE mRv CERRFCARONS INDCATED HERON SHALL RW ONLY TO ME PERSON(S)FOR WHOM THE SURVEY IS PREPARED AND ON HIS BEHALF TO THE nMECOMPANY,GOVERNMENTALAGENCYAND LENDNG INSTITUTION LISTED HEREON,AND TO THE ASS'GNEES OF THE LENDING INSTI lUTION.CE-FICATIONS ARE NOT TRANSFERABLE 70 ADDITIONAL INSTITUTIONS OR SUBSEQUENT OWNERS CERTIFIED TO:MADI DROEGE ' JOB NO. 2015-280 MAP NO. 5859 FILED:JANUARY 26,1973 REVISIONS: UPDATE SURVEY 11812021 REV.PROP. PARKING 21212021 F Or- NEIN}. ADD DIMESNIONS TO ,`q� ` 0 EXISTING DECKq 'r ADD SQ.FT. TO ALL IMPERVIOUS ITEMS 7123125 O LAND Svc O ' JEFFREY W.HADERER L.S. n NYS LIC.NO.:050538 �� v/ <11 TWIN FORKS LAND SURVEYING 0 SUCCESSOR 70 HANDS ONSURVEYMG S,MAR77ND.HANOL 188 W.MONTAUK HIGHWAY,UNIT E3 0 l•^"" O HAMPTONRAYS,NEWYORK 11946 '9 ma631-369r8312 Aslw-(F)63*oo..co y J` VA email:nvinfoTkslmrdsTvvey�ayahoo.com yY �-�0� 2.AA_ ' COPIES OF THIS SURVEYMAP,EITHER PAPER ORELECTRONIC,NOTBEATHE LAND SVERING /'`! O RS INKED SEAL OR EMBOSSED SL SHALL NOTBE CONSIDERED TOUBEA VALID COPYAND SHALL NOT BE USED FO ANY PURPOSE. LOTAREA:44,214 SQ.FT. = 1.015ACRES M LOT COVERAGE:6,170 SQ.FT, = 14.0%(DOES NOT INCLUDE OVERLAPS) DWELLING:Z932 SQ.FT. FRONT PORCH.50 SQ.FT. STAKEFOUND \ \ NO TACK \ \ DRONT STEPS: 18 SQ.FT. \ � _ FRONT WALKWAY.-160 SQ.FT. W 1 FRONT OVER HANGS:94 SQ.FT. z 1 GREEN HOUSE SHED: 107 SQ.FT. `eo WOOD RAMP&PLAT. 26 SQ.FT, WOOD DECK: 1,305 SQ.FT. C.E&STEPS:28 SQ.FT. &36 SQ.FT. WEST STEPS TO POOL PATIO: 13 SQ.FT. W \ °0 NORTH STEPS:56 SQ.FT. STAKE FOUND 2nd FLOOR DECK OVER 1st FLOOR DECK.347 SQ.FT. �,ST CONC. SLAB:49 SQ.FT. o \q� PROPOSED STAIRCASE: 100 SQ.FT. (38 SQ.FT. OVER CONC. SLAB) POOL:510 SQ.FT, z ry\ \ \ COPING:73 SQ.FT. PATIO:621 SQ.FT. STAKEFOUND a NO TACK ��°IQ y�i \ Q SAUNA:30 SQ.FT. 1D.3'x1O4'•f07SF gW• \! \ � \ } V GREEUSE 2 m /N \ eD _I LTE 'lQ'p Lu_► AND p°1211 Mq �O° \ OHO\G� M U) LATE 2.6'W 117 m Lu UNDERG / 1' O O�J� 5'x 6' PROPANE q K° .s zje, 3SF ryLr,, \ -`�OpO 6g O FRANA 11.2'W FC STN�ACKK D 1�. t4.a--'zN0 30gs,Q \ 30 SF CON ON' 0.7'E Q I"� 3S0 o�s0"q°O,12y�Dp \ 0O E O Lu5 h ak SSCO�N�C pR O I O jz \ 3 4g"yB STq/l -° z HEDGE ,^'a a°• '?a.`` SP ; S TO \ Q D 2.cw 19.0 �O' \ eay F z 31.0 g \ 6'. Ug2�T3 721, Su 3 K z b T21 ry 2 ��Ary�j OO,p PR,yy .1 1Z7, � ay ry 1I a`O6ND o• cnL '� ° L \ ?ham C,U ��• R III;, OpR Nry�, Lu Alk S SP Nt ° LLo 6 --20.5 dCn � L~n ONC.MON. F v FOUND 0.5'E -w� J `V E SURVEY OF LOT 6 AUG 1 2 2025 MAP OF Southold Town PETTY'S BIGHT SITUA TE A T EASEMEM SMALLSUBSURFACE Boafd Of TNStBBS STRUCOREDARE OTGUA STRUC70REREC RDEDO RANTEED UNLESS PHYSICALLY EV/OEMAT THE nMEOFSURVEY. ORIENT THEOFFSET(ORWMENSIONSJSHOWN NEREONFROMTN1=20TURES M&E FROPERTYUNESAREFORASPEGFIC TOWN OF SOUTHOLD PURPOSEANDUMTOG IDETHE ERUORE AREN071MEFaC S.WAETHE WALLS,NOFFENCES.REAMING SUFFOLK COUNTY NEW YORK WALLS.PoOLS,PATIOS.UWNGPLANING l ANDANY07HO�WNSBTFULCCnON S.C.T.M. 1000 SEC. 14 BLK. 02 LOT 24 UNAUTHOMMDAlTERA770NORADOMM SE UO GR OFTH Nro YOIWS SECCA77ON 90F THE NEW YORKSTATE EOUCARONIAW. 20 10 0 20 40 60 80 100 120 140 160 180 OlEL DSURVE 0RSl WSfA 0R NO SCALE. 1 40 DATE.OCTOBER 9, 2015 TOBA VAURVEYORS INKED SEA OR „= T EMBOSSEDSEAL SHALL NOTSECONSIDERED 70 BEA VALID n7lECOPY. OMNI.YFM THE N7SOONAAI FB N�M1IOMSHALL RUN THEBURVEY IS PREPAREDANDON HIS BEHALF TO THE UTLECOMPANY.GO VERNMENTALAGENCYAND LENMG INSnTUnON USTEOHEREON.AND M THEASSIGNEES OF THELENUNG INS17- =0N.CERnFICANNSARENOT TRANSFERABLE TOADOInONALtHs?7wum0R SUlllMUENT OWNERS. 0 LD TRU TE H ES UT No. 1o846=a ; lssuedi - T -. Nlac�e� ►nt, 17roP�q� Date! dress . ... ' gg5 Pettws �r;�e ore�< THIS NOTICE MUST BE DISPLAYED DURING CONSTRUCTION TOWN TRUSTEES OFFICEJOWN OF SOUTHOLD SOUTHOLD N.Y. 11971 TEL.: 76.5.1892 Glenn Goldsmith,President Y����0 COGy�N Town Hall Annex A.Nicholas Krupski,Vice President c < 54375 Route 25 Eric Sepenoski P.O.Box 1179 Liz Gillooly �y�• �01� Southold,NY 11971 Elizabeth Peeples Telephone(631)765-1892 Fax(631)765-6641 Southold Town Board of Trustees Field Inspection Report Date/Time: ZnS- Completed in field by: Douglas McGahan on behalf of MADELINE C. DROEGE FAMILY REVOCABLE TRUST, DATED MAY 29, 2013 requests an Administrative Permit for the as-built: removal of existing wood decking and installation of 1305 sq.ft. composite decking. Located: 885 Pettys Drive, Orient. SCTM# 1000-14-2-24 Type off=rea to be impacted: saltwater Wetland Freshwater Wetland �ound Bay Part of Town Code proposed work falls under: Chapt. 275 Chapt. 111 other Typ�op lication: Wetland Coastal Erosion Amendment istrative Emergency Pre-Submission Violation Notice of Hearing card posted on property: --'�es No Not Applicable Info needed/M dification Conditions/Etc.: l j . �r Present Were: G. Goldsmith N. Krupski E. Sepenoski L. Gillooly E. Peeples f i r A� 0000 .. •,*6, .'' --- - - qlwww / 1 � Revriva w xiw ae-0}o9 of-zaot Be fe-0d ' tazr-0B talala aazald i« P.D.65 LD ' S0N0 a t+Mc10 cE IN,m , 'G 16 uWq ,. SIVlc1 m � m 119 R' 312 SA>1c1 ni L1AM Ito o t kcl v 3t3 pE ^ ie s BWc1 saAR) m of,r�/ }u a n, mp'? YstAlO 50UN0 / 613 j'PO 65•\.. t.A(c) Q4 its im a / $ D. L nd ]I1 '\4 . 115£ffy Bwuuo,urrnawl /.�sj M o O �` � O .321 w a'(e'er 3355 tl Y /D 'SDN� 1 ,. Iw ��� •` FOR FCE No. I' �,BOAIcSxS ;E" ^^, c1 xaA(cl '� 6 SEE SEC.NO. nax+ dlta' `lk. IWO }al x32 ® Ot0-01-002x t.aµq ., m flyfa s sane aaa 10 �„ i sax n m � uAlaB xaa I ♦]A(c) FOR KL 139 NO. FOR 1—NO. FORP0.NO.SEE SEC.NO. SEE SEG 0. 12 01.,`L / axa §_ }d ' ��\i n SEE SEC.NO. a@-010.1 @aw-0w.5 Iz 5 f otamatxx A�NN '52A(l) OLD MNN u� to RO. Rp la - f._.__'___---- -----Z---i-- --- —uNE .14 t 1T2 _ atoll mt• SEE SEC.N0.O1B t $EE SEO NO.OIB Qj 6 B 16 tT.t S.R.25 fe67 4 E '^ — —' �" ^ ae c NOTICE .t wtpy COUNTY OF SUFFOLK © E tm a SOU7HOLD SECTION NO c Q m bt Real Property Tax Service Agency v 014 E �.r.. —,_—.�--_ Y -- -- -- � \T11 no�nlY Contcr Rlra�M1oaq NY11B01 M 0 E� mmTlNn.au 111JJJ%%% n p.><.�. v ... . w —_._— a..,�--ti-- '21aswD P B tRct.o 1D00 PROPERTY MAP mxnxvwwtc u.�B.wi. _ OFFICE LOCATION: „"� Q ` Q!lrOl�,, MAILING ADDRESS: Town Hall Annex z' '' !t P.O.Box 1179 54375 State Route 25 ? Southold, NY 11971 (cor. Main Rd. &Youngs Ave.) g Telephone:631765-1998 Southold,NY 11971 ► • _ �4: , LOCAL WATERFRONT REVITALIZATION PROGRAM TOWN OF SOUTHOLD To: Glenn Goldsmith, President Town of Southold Board of Trustees cc: Honorable Lori Hulse, Attorney From: Heather Lanza, AICP, Planning Director LWRP Coordinator Date: September 15, 2025 Re: LWRP Coastal Consistency Review MADELINE C. DROEGE FAMILY REVOCABLE TRUST, DATED MAY 29, 2013 SCTM# 1000-14-2-24 The application referenced above is for an Administrative Permit for the removal of as- built existing wood decking and installation of 1,305 sq. ft. composite decking. The proposed action has been reviewed to Chapter 268, Waterfront Consistency Review of the Town of Southold Town Code and the Local Waterfront Revitalization Program (LWRP) Policy Standards. Based upon the information provided on the LWRP Consistency Assessment Form submitted to this department, as well as the records available to me, it is my recommendation that the action is INCONSISTENT with the Policy Standards listed below, and therefore is INCONSISTENT with LWRP. 6.3 Protect and restore tidal and freshwater wetlands. A. Comply with statutory and regulatory requirements of the Southold Town Board of Trustees laws and regulations for all Andros Patent and other lands under their jurisdiction The deck was originally built without a Wetland Permit. The construction of structures without a permit from the Town Trustees is not consistent with this policy. Pursuant to Chapter 268, the Board of Trustees shall consider this recommendation in preparing its written determination regarding the consistency of the proposed action. e. �9.'.... . :9 �J Glenn Goldsmith, President aa�®� SOU� Town Hall Annex V� ®A. Nicholas Krupski,Vice President e�� �® 54375 Route 25P.O. Box 1179 Eric Sepenoski J8 Southold,New York 11971 Liz Gillooly G @ Telephone(631) 765-1892 Elizabeth Peeples Fax(631) 765-6641 00 Nri,� BOARD OF TOWN TRUSTEES TOWN OF SOUTHOLD This Section For Office Use Only Coastal Erosion Permit Application Wetland Permit Application '�, Administrative Permit Amendment/Transfer/Extension _ )C Received Application: va% ?(- Received Fee: $ 500 - 00 Completed Application: Incomplete: SEQRA Classification: Type I Type 11 Unlisted Negative Dec. Positive Dec. Lead Agency Determination Date: Coordination:(date sent): �LWRP Consistency Assessment Form Sent: 9151 DR � E 6 V E CAC Referral Sent: Date of Inspection: Olt b I'�S AUG 1 2 Receipt of CAC Report: 2 225 Technical Review: Public Hearing Held: q ll aS Southold Town . Resolution: Board of Trustees C . 1�roe5� FGn,.'1� ?tvoccl) T��S\ Owner(s) Legal Name of Property (as shown on Deed): t�i�ka3 U�-��1�'4a Y-��% MGH a� Mailing Address: c 1.� -t PQ`'k-\'rC 6 Phone Number: 0 - )"1 01 Suffolk County Tax Map Number: 1000 - Property Location: i i-'3-)n"l G j2��..j Uon iSe-9 (If necessary, provide LILCO Pole#, distance to cross streets, and location) AGENT (If applicable): v'-s C, 6k-i-1 � rt Mailing Address: 'i Phone Number: �� 1 ` tJ � Email: ��t�Ajq '�"a) s1tJ r r fie• BI d of Trustees Application GENERAL DATA Land Area (in square feet): 4��j , >C Ll Area Zoning: Previous use of property: G-L ul 2� S I h E0 Intended use of property: 11�C Covenants and Restrictions on property? Yes �j No If"Yes", please provide a copy. Will this project require a Building Permit as per Town Code? Yes No If"Yes", be advised this application will be reviewed by the Building Dept. prior to a Board of Trustee review and Elevation Plans will be required. Does this project require a variance from the Zoning Board of Appeals? Yes ',-4 No If"Yes", please provide copy of decision. Will this project require any demolition as per Town Code or as determined by the Building Dept.? Yes '-P No Does the structure (s) on property have a valid Certificate of Occupancy? Yes No Prior permits/approvals for site improvements: Agency Date �5 ,S Zoo �yS26 Zci l No prior permits/approvals for site improvements. Has any permit/approval ever been revoked or suspended by a governmental agency? y- No Yes If yes, provide explanation: Project Description (use attachments if necessary): 711:��\ CIV aV( ) k-1J0C;1-) B d of Trustees Applicatioi WETLAND/TRUSTEE LANDS APPLICATION DATA Purpose of the proposed operations: Area of wetlands on lot: square feet Percent coverage of lot: 4 11 % Closest distance between nearest existing structure and upland edge of wetlands: 2 4,)n' feet Closest distance between nearest proposed structure and upland edge of wetlands: Z w-0- feet Does the project involve excavation or filling? _No Yes If yes, how much material will be excavated? cubic yards How much material will be filled? cubic yards Depth of which material will be removed or deposited: feet Proposed slope throughout the area of operations: ' Manner in which material will be removed or deposited: Statement of the effect, if any, on the wetlands and tidal waters of the town that may result by reason of such proposed operations (use attachments if appropriate): 617.20 Appendix B Short Environmental Assessment Form Instructions for Completing Part 1 -Project Information. The applicant or project sponsor is responsible for the completion of Part 1. Responses become part of the application for approval or funding,are subject to public review,and may be subject to further verification. Complete Part 1 based on information currently available. If additional research or investigation would be needed to fully respond to any item,please answer as thoroughly as possible based on current information. Complete all items in Part 1. You may also provide any additional information which you believe will be needed by or useful to the lead agency;attach additional pages as necessary to supplement any item. Part 1 -Project and Sponsor Information Name of Action or Project: Project Location(describe,and attach a location map): Brief Description of Proposed pAction: } `j� y [� <•y P , +1•\..��cC�� •��� V �S �7 Ir Name of Applicant or Sponsor: Telephone: ��t.{� _ k_tj- � E-Mail: Address: City/PO: State: Zip Code: 1.Does the proposed action only involve the legislative adoption of a plan,local law,ordinance, NO YES administrative rule,or regulation? If Yes,attach a narrative description of the intent of the proposed action and the environmental resources that may be affected in the municipality and proceed to Part 2. If no,continue to question 2. 2. Does the proposed action require a permit,approval or funding from any other governmental Agency? NO YES If Yes,list agency(s)name and permit or approval: 19 ❑ 3.a. Total acreage of the site of the proposed action? acres b.Total acreage to be physically disturbed? acres c.Total acreage(project site and any contiguous properties)owned or controlled by the applicant or project sponsor? acres 4. Check all land uses that occur on,adjoining and near the proposed action. ❑Urban ❑Rural(non-agriculture) ❑Industrial ❑Commercial EIResidential(suburban) ❑Forest ❑Agriculture El Aquatic ❑Other(specify): ❑Parkland Page 1 of 4 5. Is the proposed action, NO YES N/A a. A permitted use under the zoning regulations? ❑ ® ❑ b.Consistent with the adopted comprehensive plan? ❑ [F�/'] ❑ 6. Is the proposed action consistent with the predominant character of the existing built or natural NO YES landscape? ❑ M 7. Is the site of the proposed action located in,or does it adjoin,a state listed Critical Environmental Area? NO YES If Yes,identify: Fil El 8. a.Will the proposed action result in a substantial increase in traffic above present levels? NO YES b.Are public transportation service(s)available at or near the site of the proposed action? ® ❑ c.Are any pedestrian accommodations or bicycle routes available on or near site of the proposed action? FZ] ❑ 9.Does the proposed action meet or exceed the state energy code requirements? NO YES If the proposed action will exceed requirements,describe design features and technologies: 10. Will the proposed action connect to an existing public/private water supply? NO YES If No,describe method for providing potable water: ES] ❑ 11.Will the proposed action connect to existing wastewater utilities? NO YES If No,describe method for providing wastewater treatment: — ❑ 12. a.Does the site contain a structure that is listed on either the State or National Register of Historic NO YES Places? ® ❑ b.Is the proposed action located in an archeological sensitive area? ❑ ❑ 13.a.Does any portion of the site of the proposed action,or lands adjoining the proposed action,contain NO YES wetlands or other waterbodies regulated by a federal,state or local agency? 57 ❑ b.Would the proposed action physically alter,or encroach into,any existing wetland or waterbody? ❑ If Yes,identify the wetland or waterbody and extent of alterations in square feet or acres: 14. Identify the typical habitat types that occur on,or are likely to be found on the project site. Check all that apply: -Shoreline ❑Forest ❑Agricultural/grasslands ❑Early mid-successional ❑ Wetland ❑Urban ❑Suburban 15.Does the site of the proposed action contain any species of animal,or associated habitats,listed NO YES by the State or Federal government as threatened or endangered? ❑ 16.Is the project site located in the 100 year flood plain? NO YES 17.Will the proposed action create storm water discharge,either from point or non-point sources? NO YES If Yes, ® ❑ a. Will storm water discharges flow to adjacent properties? ❑NO ❑YES b.Will storm water discharges be directed to established conveyance systems(runoff and storm drains)? If Yes,briefly describe: ❑NO ❑YES Page 2 of 4 \1 18. Does the proposed action include construction or other activities that result in the impoundment of NO YES water or other liquids(e.g.retention pond,waste lagoon,dam)? If Yes,explain purpose and size: 19. Has the site of the proposed action or an adjoining property been the location of an active or closed NO YES solid waste management facility? If Yes,describe: R ❑ 20.Has the site of the proposed action or an adjoining property been the subject of remediation(ongoing or NO YES completed)for hazardous waste? If Yes,describe: 1 ❑ I AFFIRM THAT THE INFORMATION PROVIDED ABOVE IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE Applicant/sponsor na fie: °� @ '� fyf yi� 5���` Date: Signature: Part 2-Impact Assessment. The Lead Agency is responsible for the completion of Part 2. Answer all of the.following questions in Part 2 using the information contained in Part 1 and other materials submitted by the project sponsor or otherwise available to the reviewer. When answering the questions the reviewer should be guided by the concept"Have my responses been reasonable considering the scale and context of the proposed action?" No,or Moderate small to large impact impact may may occur occur 1. Will the proposed action create a material conflict with an adopted land use plan or zoning El ❑ regulations? 2. Will the proposed action result in a change in the use or intensity of use of land? ❑ ❑ 3. Will the proposed action impair the character or quality of the existing community? ❑ ❑ 4. Will the proposed action have an impact on the environmental characteristics that caused the El ❑ establishment of a Critical Environmental Area(CEA)? 5. Will the proposed action result in an adverse change in the existing level of traffic or El ❑ affect existing infrastructure for mass transit,biking or walkway? 6. Will the proposed action cause an increase in the use of energy and it fails to incorporate ❑ ❑ reasonably available energy conservation or renewable energy opportunities? 7. Will the proposed action impact existing: ❑ ❑ a.public/private water supplies? b.public/private wastewater treatment utilities? 8. Will the proposed action impair the character or quality of important historic,archaeological, ❑ ❑ architectural or aesthetic resources? 9. Will the proposed action result in an adverse change to natural resources(e.g.,wetlands, El ❑ waterbodies,groundwater,air quality,flora and fauna)? Page 3 of 4 No,or Moderate small to large impact impact may may occur occur 10. Will the proposed action result in an increase in the potential for erosion,flooding or drainage ❑ Elproblems? 11. Will the proposed action create a hazard to environmental resources or human health? Part 3-Determination of significance. The Lead Agency is responsible for the completion of Part 3. For every question in Part 2 that was answered"moderate to large impact may occur",or if there is a need to explain why a particular element of the proposed action may or will not result in a significant adverse environmental impact,please complete Part 3. Part 3 should,in sufficient detail, identify the impact, including any measures or design elements that have been included by the project sponsor to avoid or reduce impacts. Part 3 should also explain how the lead agency determined that the impact may or will not be significant. Each potential impact should be assessed considering its setting,probability of occurring, duration, irreversibility,geographic scope and magnitude: Also consider the potential for short-term, long-term and cumulative impacts. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action may result in one or more potentially large or significant adverse impacts and an environmental impact statement is required. Check this box if you have determined,based on the information and analysis above,and any supporting documentation, that the proposed action will not result in any significant adverse environmental impacts. Town of Southold-Board of Trustees Name of Lead Agency Date President Print or Type Name of Responsible Officer in Lead Agency Title of Responsible Officer Signature of Responsible.Offiicer in Lead Agency Signature of Preparer(if different from Responsible Officer) PRINT Page 4 of 4 APPLICANT/AGENT/REPRESENTATIVF TRANSACTIONAL DISCLOSURE FORM The Town of Southold's Code of Ethics grohibits conflicts of interest on the part of town officers and employees.The purpose of this form is to provide information which can alert the town of Possible conflicts of interest and allow it to take whatever action is necessary to avoid same. -"��"-' YOUR NAME: //�'! �/ y e//�� (Last name,first name,zxiiddl`e'initial,unless you are applyi g in the name of someone else or other entity,such as a company.If so,indicate_the other person's or company's name.) NAME OF APPLICATION: (Check all that apply.) a / Tax grievance Building v Variance Trustee Change of Zone Coastal Erosion Approval of plat Mooring Exemption from plat or official map Planning Other (If"Other',name the activity.) Do you personally(or through your company,spouse,sibling,parent,or child)have a relationship with any officer or employee of the Town of Southold? "Relationship"includes by blood,marriage,or business interest."Business interest"means a business, including a partnership,in which the town officer or employee has even a partial ownership of(or employment by)a corporation in which the town officer or employee owns more than 5%of the shares. YES NO If you answered"YES",complete the balance of this form and date and sign where indicated. Name of person employed by the Town of Southold Title or position of that person Describe the relationship between yourself(the applicant/agent/representative)and the town officer or employee.Either check the appropriate line A)through D)and/or describe in the space provided. The town officer or employee or his or her spouse,sibling,parent,or child is(check all that apply): A)the owner of greater than 5%of the shares of the corporate stock of the applicant (when the applicant is a corporation); B)the legal or beneficial owner of any interest in a non-corporate entity(when the applicant is not a corporation); C)an officer,director,partner,or employee of the applicant;or D)the actual applicant. DESCRIPTION OF RELATIONSHIP Submitted this day of _(( ('• 200 `2- Signature Print Form TS 1 e E -�.:d of Trustees Applicatio AUTHORIZATION (Where the applicant is not the owner) I/We, c-�/ owners of the property identified as SCTM# 1000- It)2, — `Z`'� in the town of New York, hereby authorizes ©•�(� >✓ M C(A A"ACV,) to act as my agent and handle all necessary work involved with the application process for permit(s) from the Southold Town Board of Trustees for this property. Property Owner's Signature Property Owne s Signature SWORN TO BEFORE ME THIS Q9F1I' DAY OF , 20 2 Nota Pu lic BRITTANYA CONRAD Notary Public,State of New York Reg.No.01C06245154 Qualified in Suffolk County Commission Expires July 18,20.,2,�l I rd of Trustees Applicatic AFFIDAVIT � �VZ non) BEING DULY SWORN DEPOSES AND AFFIRMS THAT HE/SHE IS THE APPLICANT FOR THE ABOVE DESCRIBED PERMIT(S)AND THAT ALL STATEMENTS CONTAINED HEREIN ARE TRUE TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AND THAT ALL WORK WILL BE DONE IN THE MANNER SET FORTH IN THIS APPLICATION AND AS MAY BE APPROVED BY THE SOUTHOLD TOWN BOARD OF TRUSTEES. THE APPLICANT AGREES TO HOLD THE TOWN OF SOUTHOLD AND THE BOARD OF TRUSTEES HARMLESS AND FREE FROM ANY AND ALL DAMAGES AND CLAIMS ARISING UNDER OR BY VIRTUE OF SAID PERMIT(S), IF GRANTED. IN COMPLETING THIS APPLICATION,I HEREBY AUTHORIZE THE TRUSTEES, THEIR AGENT(S) OR REPRESENTATIVES, INCLUDING THE CONSERVATION ADVISORY COUNCIL, TO ENTER ONTO MY PROPERTY TO INSPECT THE PREMISES IN CONJUNCTION WITH THIS APPLICATION, INCLUDING A FINAL INSPECTION. I FURTHER AUTHORIZE THE BOARD OF TRUSTEES TO ENTER ONTO MY PROPERTY AND AS REQUIRED TO INSURE COMPLIANCE WITH ANY CONDITION OF ANY WETLAND OR COASTAL EROSION PERMIT ISSUED BY THE BOARD OF TRUSTEES DURING THE TERM OF THE PERMIT. Signature of Property Owner Signature of Prope y Owner SWORN TO BEFORE ME THIS GL � DAY OF C�� � , 20 Notary Pu lic )eN ANY A CONRAD Notalic,State of New York o.o1C06245154 oualified in Suffolk County Commission Expires July 181 20? I Town of Southold LWRP CONSISTENCY ASSESSMENT FORM A. INSTRUCTIONS 1. All applicants for permits* including Town of Southold agencies, shall complete this CCAF for proposed actions that are subject to the Town of Southold Waterfront Consistency Review Law. This assessment is intended to supplement other information used by a Town of Southold agency in making a determination of consistency. *Except minor exempt actions including Building Permits and other ministerial permits not located within the Coastal Erosion Hazard Area. 2. Before answering the questions in Section C, the preparer of this form should review the exempt minor action list, policies and explanations of each policy contained in the Town of Southold Local Waterfront Revitalization Program. A proposed action will be evaluated as to its si frog icant beneficial and adverse effects upon the coastal area(which includes all of Southold Town). 3. If any question in Section C on this form is answered "yes" or "no", then the proposed action will affect the achievement of the LWRP policy standards and conditions contained in the consistency review law. Thus, each answer must be explained in detail, listing both supporting and non- supporting facts. If an action cannot be certified as consistent with the LWRP policy standards and conditions,it shall not be undertaken. A copy of the LWRP is available in the following places: online at the Town of Southold's website (southoldtown.northfork.net), the Board of Trustees Office, the Planning Department, all local libraries and the Town Clerk's office. B. DESCRIPTION OF SITE AND PROPOSED ACTION SCTM# ° _- ®2— PROJECT NAME The Application has been submitted to (check appropriate response): Town Board ❑ Planning Board❑ Building Dept. ❑ Board of Trustees 1. Category of Town of Southold agency action(check appropriate response): (a) Action undertaken directly by Town agency(e.g. capital ❑ construction,planning activity, agency regulation, land transaction) ❑ (b) Financial assistance (e.g. grant, loan, subsidy) (c) Permit, approval, license, certification: Nature and extent of action: i a Location of action: Site acreage: 'Q Present land use: De, 05 Present zoning classification: 2. If an application for the proposed action has been filed with the Town of Southold agency, the following information shall be provided: (a) Name of applicant: (b) Mailing address: (c) Telephone number: Area Code ( ) (d) Application number, if any: Will the action be directly undertaken,require funding, or approval by a state or federal agency? Yes ❑ No❑ If yes, which state or federal agency? C. Evaluate the project to the following policies by analyzing how the project will further support or not support the policies. Provide all proposed Best Management Practices that will further each"policy. Incomplete answers will require that the form be returned for completion. DEVELOPED COAST POLICY Policy 1. Foster a pattern of development in the Town of Southold that enhances community character, preserves open space, makes efficient use of infrastructure, makes beneficial use of a coastal location, and minimizes adverse effects of development. See LVW Section III—Policies; Page 2 for evaluation criteria. ❑Yes ❑ No ® Not Applicable Attach additional sheets if necessary Policy 2. Protect and preserve historic and archaeological resources of the Town of Southold. See LWRP Section III—Policies Pages 3 through 6 for evaluation criteria El Yes ❑ No 0) Not Applicable Attach additional sheets if necessary Policy 3. Enhance visual quality and protect scenic resources throughout the Town of Southold. See LWRP Section III—Policies Pages 6 through 7 for evaluation criteria ❑ Yes ❑ No E Not Applicable Attach additional sheets if necessary NATURAL COAST POLICIES Policy 4. Minimize loss of life, structures, and natural resources from flooding and erosion. See LWRP Section III—Policies Pages 8 through 16 for evaluation criteria ❑ Yes ❑ No Not Applicable Attach additional sheets if necessary Policy 5. Protect and improve water quality and supply in the Town of.Southold. See LWRP Section III —Policies Pages 16 through 21 for evaluation criteria ❑ Yes ❑ No 1?5Not Applicable Attach additional sheets if necessary Policy 6. Protect and restore the quality and function of the Town of Southold ecosystems including Significant Coastal Fish and Wildlife Habitats and wetlands. See LWRP Section III—Policies; Pages.22 through 32 for evaluation criteria. ❑ ❑ L�`J l Yes No Not Apj .-able Attach additional sheets if necessary Policy 7. Protect and improve air quality in the Town of Southold. See LWRP Section III — Policies Pages 32 through 34 for evaluation criteria. ❑ Yes [—] No[�j Not Applicable Attach additional sheets if necessary Policy 8. Minimize environmental degradation in Town of Southold from solid waste and hazardous substances and wastes. See LWRP Section III—Policies; Pages 34 through 38 for evaluation criteria. ❑ Yes ❑ No 1� Not Applicable PUBLIC COAST POLICIES Policy 9. Provide for public access to, and recreational use of, coastal waters, public lands, and public resources of the Town of Southold. See LWRP Section III—Policies; Pages 38 through 46 for evaluation criteria.❑ Ye n No 111�Not Applicable Attach additional sheets if necessary WORKING COAST POLICIES Policy 10. Protect Southold's water-dependent uses and promote siting of new water-dependent uses in suitable locations. See LWRP Section III Policies; Pages 47 through 56 for evaluation criteria. ❑ Yes ❑ No [�] Not Applicable Attach additional sheets if necessary Policy 11. Promote sustainable use of Paving marine resources in Long Island Sound, the Peconic Estuary and Town waters. See LWRP Section III—Policies; Pages 57 through 62 for evaluation criteria. ❑ Yes ❑ No D Not Applicable Attach additional sheets if necessary Policy 12. Protect agricultural lands in the Town of Southold. See LWRP Section III — Policies; Pages 62 through 65 for evaluation criteria. ❑ Yes ❑ No ® Not Applicable Attach additional sheets if necessary Policy 13. Promote appropriate use and development of energy and mineral resources. See LWRP Section III—Policies; Pages 65 through 68 for evaluation criteria. ❑ Yes ❑ No 0' Not Applicable PREPARED BY TITLE DATE T